The SA Journal Diabetes & Vascular Disease Vol 15 No 1 (July 2018)

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40 VOLUME 15 NUMBER 1 • JULY 2018
DIABETES GUIDELINES SA JOURNAL OF DIABETES & VASCULAR DISEASE
Equally, the guidelines provide detailed considerations for use of
the other agents, including pioglitazone, DPP-4 inhibitors and
SGLT-2 inhibitors.
Hypoglycaemia
Hypoglycaemia is an important limitation in achieving optimal
glycaemic control and is a significant risk factor for cardiovascular
mortality and morbidity, especially in those with pre-existing
cardiovascular disease. It is defined as SMBG < 3.9 mmol/l, with
significant hypoglycaemia < 3 mmol/l. Severe hypoglycaemia is any
low blood glucose value accompanied by cognitive dysfunction
and the need for external assistance to correct the hypoglycaemia.
Patients at risk of hypoglycaemia (Table 3) require education to
recognise and treat hypoglycaemic episodes (with confirmation
of hypoglycaemia with SMBG wherever possible). Oral glucose
(15–20 g) is the preferred treatment for non-severe episodes and
intravenous (IV) 50% dextrose water for severe hypoglycaemia. In
the event of no IV access, 1 mg subcutaneous or intramuscular
glucagon may be administered.
Any episode of severe hypoglycaemia or hypoglycaemia
unawareness requires re-evaluation of the treatment regimen and
patients. Patients with recurrent episodes should be referred to
specialist care.
Cardiovascular risk management
• Statins are the first-line agents for lowering LDL cholesterol in
patients with type 2 diabetes. They should be added to lifestyle
therapy regardless of baseline lipid levels in all patients with
pre-existing cardiovascular disease, chronic kidney disease
(eGFR < 60 ml/min/1.72 m2) and in those aged ≥ 40 years or
with diabetes duration ≥ 10 years and with ≥ one additional
cardiovascular risk factors.
• Low-dose aspirin therapy is strongly recommended for
secondary prevention of cardiovascular disease in patients with
Table 3. Characteristics of patients at high risk of hypoglycaemia
• Treatment with insulin and/or insulin secretagogues (sulphonylurea and
meglitinides)
• Intensive glucose control
• Use of more than two glucose-lowering drugs
• Older age
• Longer duration of diabetes
• Hypoglycaemia unawareness
• Impaired cognitive function
• Low body mass index
• Renal or hepatic impairment
• Microvascular complications
• Patients who exercise or skip meals
• Excessive alcohol intake
type 2 diabetes, but is not recommended for primary prevention
in those who have not yet had a cardiovascular event.
• Blood pressure (BP) should be measured at every routine visit to
the healthcare professional. The threshold for treatment initiation
is > 140/90 mmHg. The treatment targets for most patients
are systolic BP 130–140 mmHg and diastolic BP 80–90 mmHg.
Suitable initial choices in patients without albuminuria include
an angiotensin converting enzyme (ACE) inhibitor, angiotensin
receptor blocker (ARB), thiazide-like diuretic (due to its widespread
availability and low cost, indapamide is the preferred diuretic) or
calcium channel blocker (CCB). Diuretics or CCBs are preferred in
black patients. ACE inhibitors, ARBs, thiazide-like diuretics and
non-dihydropyridine CCBs have been shown to be of benefit in
diabetic kidney disease. CCBs should be avoided in patients with
heart failure, and beta-blockers should be avoided in patients at
high risk of stroke. ACE inhibitors and ARBs should not be used
in combination.
Additional information
The following practical tools and patient support aids are included
in the appendices of the 2017 SEMDSA diabetes management
guidelines:
Appendix 13a: Algorithm for the management of hyperglycaemic
emergencies.
Appendix 13b: Diabetic coma chart.
Appendix 14: Treatment algorithm for in-hospital management of
diabetes.
Appendix 21: Diabetes foot-care patient checklist; diabetic foot-
screening assessment form; foot abnormalities and footwear
illustrations; practical guide to neuropathy assessment; care
pathway for people with diabetic foot problems.
Appendix 26: Examples of Ramadan-specific meal plans for South
Africans.
Appendix 29: Assessment and treatment algorithm for sexual
dysfunction in men with type 2 diabetes.
Acknowledgement
This article is based on a presentation by Dr A Amod at the 52nd
congress of the Society of Endocrinology, Metabolism and Diabetes
of South Africa (SEMDSA) in Johannesburg in May 2017 and the
SEMDSA 2017 guidelines for the management of type 2 diabetes
mellitus. The article was written for deNovo Medica by Dr David
Webb.
The latest complete pdf version of the guideline is available at
Reference
The Society of Endocrinology, Metabolism and Diabetes of South Africa Type 2 Diabetes
Guidelines Expert Committee. The SEMDSA 2017 guidelines for the management of
type 2 diabetes mellitus. J Endocrinol, Metab Diabetes S Afr 2017; 22(1): S1–S182.